Last July, activists lambasted the Obama administration and other rich countries at the International AIDS Conference in Vienna, claiming that the current flat funding of global AIDS programs breaks prior commitments to universal treatment and threatens the lives of millions of people with HIV. The Obama administration has defended its commitment to fight HIV, but close examination shows a flattening of resources just when more people have joined the waiting lists for treatment.

The Facts on Funding

According to UNAIDS, annual funding for AIDS from all sources slowly crept up in the 1990s, from only $200 million to $1 billion. In contrast, between 2000 and 2009, AIDS commitments increased dramatically, from $1.4 billion to nearly $16 billion a year less than half of which comes from rich country donors. But in 2009, donor commitments plateaued and disbursements actually dropped for the first time.

First, it's important to distinguish between donors' stated commitments and the actual money spent. During the past eight years there has been a $7.9 billion difference between the two!

2002

2003

2004

2005

2006

2007

2008

2009

Commitments

1.6

2.0

3.6

4.3

5.6

6.6

8.7

8.7

Disbursements

1.2

1.6

2.8

3.5

3.9

4.9

7.7

7.6

U.S. commitments increased dramatically over the past eleven years, until they too flattened. Using Kaiser Foundation figures that combine funding for HIV prevention, treatment, and care, U.S. funding shows eight years of growth followed by stagnation. U.S. appropriations to the Global Fund to Fight AIDS, Tuberculosis and Malaria during the same time period fluctuated, but show an overall tenfold increase followed by three years of flat funding.

On the campaign trail, Barack Obama, Joe Biden, and Hillary Clinton all pledged $50 billion for global AIDS over five years. That would have meant increasing AIDS spending by nearly $1.5 billion a year for five years. In 2008, the Lantos-Hyde Act reauthorizing PEPFAR (the President's Emergency Fund for AIDS Relief) approved at least $39 billion for HIV and another $9 billion for TB and malaria. That would have meant a $.6 billion increase each year, from $5.4 billion in 2010 to $8.4 billion in 2013. Instead, we have had steady-state funding at roughly $6 billion for three straight years and projections of near flat-funding for the next three years as well.

The above graph includes actual and projected U. S. funding for PEPFAR (minus R&D and TB funding) and the Global Fund, in billions of dollars. (The projections are based on the PEPFAR II authorization of $39 billion, Obama's campaign pledge of $50 billion, actual U.S. contributions to the Global Fund, and U.S. contributions required to meet its 1/3 donor fair share of the Global Fund.) About 40% of the Global Fund budget goes to TB and malaria, so U.S. commitments to global HIV alone could be reduced accordingly in the graph.

Based on these data, it is hard to understand how the Obama administration claims that it has not flat-lined global AIDS funding. True, in absolute dollar figures, overall funding has increased $300 million, or 5%, over a three-year period. But once we take into account inflation, the actual rate of funding is flat or worse. Activists contrast what is actually being delivered to the promises made during the 2008 Presidential campaign. Then, Obama's AIDS platform stated: "He has pledged to provide at least $50 billion by 2013 for the global fight against HIV/AIDS, including our fair share of the Global Fund, in order to at least double the number of HIV-positive people on treatment and continue to provide treatments to one-third of all those who desperately need them."

But the Obama administration's new health policies may cement a funding stranglehold. Earlier this year, President Obama announced his Global Health Initiative (GHI), which plans to expand U.S. funding for maternal and child health, sexual and reproductive health, neglected diseases, and overall health system strengthening. The GHI proposes $63 billion over six years, including $51 billion for AIDS, TB, and malaria. This works out to only $8.5 billion a year for all three diseases, instead of the $9.6 authorized by the Lantos-Hyde Act. A leaked report from administration sources projected total AIDS spending of only $37 billion over six years, guaranteeing that flat funding will continue. Fully funding PEFPAR (as opposed to Obama's flat budgets) would mean:

1.3 million more people could receive HIV treatment.

3.9 million more women could receive services to prevent mother-to-child transmission.

36 million more people could access programs to prevent sexual transmission of HIV.

Ineffectual Excuses

Why is the administration cranking back the fiscal faucet? After all, President Obama has announced a domestic national AIDS policy for the first time, and he is committed to the benign exercise of U.S. global power. Moreover, he has mounted such a vigorous defense of his policy -- with reports he is "hurt" by the criticism -- that it would appear he does care about global health justice.

The President may have his own misconceptions, but he is also being bombarded with disinformation. He is partially under the sway of neo-orthodox health policy wonks like White House advisor Zeke Emanuel, who espouses investing in lower-cost public health initiatives. Using the deadly tools of cost-efficiency, Emanuel and other health pundits like Mead Over, Bill Easterly, and Laurie Garrett consistently advise the President that he must avoid escalating investments in treatment and must instead prioritize HIV prevention. They argue that we should shift investments to cheaper child and maternal health programs and overall health system strengthening.

Prevention vs. Treatment

Suggesting a battle between prevention and treatment has been a long-standing mantra from certain public-health advocates, starting with the World Bank in the 1990s. You can't read an article about global AIDS without quotes from Bill Gates or Dr. Emanuel saying, "We can't treat our way out of this pandemic." Certainly, the U.S. needs to increase its investments in evidence-based, comprehensive prevention strategies that address the epidemic's structural, behavioral, and biological drivers. Certainly it should continue to spend a significant portion of its resources on comprehensive sex education, male and female condoms, promotion of delayed sexual initiation, partner reduction, circumcision, needle exchange, and new technologies like microbicides. But we must simultaneously continue the scale-up of treatment -- saving lives and achieving prevention goals are both important.

Behavioral changes are linked to people knowing their HIV status and receiving prevention counseling -- and the greatest incentive to HIV testing is the availability of treatment. Moreover, growing evidence shows that HIV treatment reduces transmission -- one study found that people in treatment were 92% less likely to transmit HIV to their spouses than those who were not. Community reductions in viral load are linked to reduced transmission in those communities. But despite this new evidence supporting treatment as prevention, the administration continues to assert that it must divert funding from treatment to its "neglected sister," prevention.

Pitting HIV against maternal and child health is equally irrational. AIDS is the leading cause of death of women of reproductive age worldwide and a leading cause of child mortality in Africa. By placing health needs in a cage of mortal combat, the administration is creating a false universe of fixed resources. Instead, women's access to HIV treatment and prevention of mother-to-child transmission should be linked with maternal health programs. Just as success in combating HIV and TB are linked, so too are public health campaigns that address neglected and noninfectious diseases. Expanding the health care workforce, strengthening health systems, and funding community-based programs will improve health outcomes across the board.

Spending Wisely

The President has also adopted the rhetoric of "country control" and "sustainability." When translated, these terms mean that the U.S. should get out of the funding game and focus on technical support -- that it should gradually reduce spending so that countries, no matter how poor, will eventually take over the fiscal burdens of prevention, treatment, and care. The President has been sold this canard because of the projected costs of future AIDS entitlements, which some cynically call the "treatment mortgage." Seeing the long line of people with HIV (34 million and counting) and the escalating costs of new first- and second-line regimens, foreign policy advisors assert that AIDS will eat up the whole health budget and that the

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President will lose his ability to leverage U.S. influence through carefully managed, carrot-and-stick foreign aid. President Obama is steadfast in his pursuit of efficiency, due to the 2008 economic meltdown. Admittedly, there has been much inefficiency in U.S. AIDS programming. PEPFAR has had irrational prevention policies that emphasize abstinence-only messaging, require a mandatory anti-prostitution pledge, and ban needle exchange programs. The U.S. at first wasted money on expensive brand-name medicines, on high overhead and fees to consultants and non-governmental organizations, and on repetitive trainings. With new efficiencies, task-shifting in the health workforce, and lower costs for generic drugs, however, the per-person cost of treatment has fallen from more than $1,000 a year to around $400. Coupled with increased monies from the countries receiving PEPFAR funding, this allowed an additional 1.2 million people to begin treatment in 2009, despite donors' reneging on promised funding increases.

The most understandable defense of flat funding is the current fiscal crisis. Government revenues have plummeted and stimulus spending has added to the national debt. At some point, analysts argue, the books must be balanced and tough choices must be made to cut spending. Global AIDS Ambassador Eric Goosby and former President Bill Clinton have argued that some of those cuts will necessarily occur in the funding promised for PEPFAR.

Activists are not arguing that the financial crisis isn't real, but that it is ultimately political -- that where there is political will, there is a way. The U.S. still has a huge economy, a huge government budget, and multiple opportunities to change priorities. If the U.S. can find hundreds of billion of dollars for war efforts in Iraq and Afghanistan, $85 billion for the auto industry, and over a trillion dollars to bail out the financial industry, surely we can find a few extra billion dollars for global health and HIV.

Waiting in Line to Die

The rate of new HIV infections dropped to 2.7 million a year (a 17% decrease) during the past decade of escalating funding. Worldwide, the number of people on treatment increased from fewer than 200,000 in 2000 (mostly in Latin America) to 5.2 million, with Africa increasing from 20,000 people to 4 million -- a whopping 20,000% increase. Similarly, coverage to prevent mother-to-child-transmission increased from essentially zero (except in Thailand and Brazil) to over 53%. And the number of people agreeing to HIV testing has escalated, so that many millions now know their HIV status and can positively plan for their future. But with the continuing threat of flat funding, the question remains: What will be the human cost?

At the Global Fund, the impact is already clear. For the past two funding rounds, it has instituted funding cuts, one called a 10% "efficiency gain," and the second a potentially reversible 25% "resource-constraint" cut for programs running over two years. But now the coffers of the Global Fund are nearly empty. It presented three options for the next round of funding: a "flatlined" budget of $13 billion, a "modest-impact" budget of $17 billion, or a "scale-up" budget of $20 billion. Regrettably, the Third Replenishment, which just took place, produced only $11.69 billion in pledges -- less than flat-lined budget option. Although the U.S. pledged $4 billion over three years (a 38% increase over its last three years of pledges), it still fell 62% short of what was needed. So, just when countries have been asked to make bigger and bolder requests, to seek funding for health system strengthening, and to create new programs for vulnerable populations, the Global Fund faces a profound funding crisis.

Similarly, the capping of PEPFAR funding led to directives in Uganda and elsewhere that "a flat-lined budget for treatment ... should not be exceeded" and that the few treatment slots available from losses to follow-up or death should be given to "the sickest patients." In the wake of this directive, thousands of people who tested HIV positive, often in late stages of immune deficiency, were told to wait in line -- in essence to die. Those who were untested would now wonder, "Why should I get an HIV test? There's nothing for me but a death sentence." For those who do test, profound ethical quandaries arose. Those who arrived in wheelbarrows, on the brink of death, would die unless they were rushed to the front of the line, postponing treatment for others whose prognosis is greatly enhanced if they start treatment while their immune systems are still functioning. Pregnant women wondered, "Should I begin treatment to reduce the risk of transmission to my baby or should I give my place in line to a baby with HIV who will otherwise die within two years?" Should husbands and wives and brothers and sisters flip coins? Or will the czars of rationing reserve scarce treatment slots for health workers, many of whom have HIV and all of whom are needed to provide desperately needed health care?

International outrage at the stark reality of these death queues, and coordinated advocacy campaigns in Africa and the U.S. led by Health GAP and its allies, resulted in an eventual reversal of the U.S. policy, at least in Uganda. A recent statement from the U.S. Ambassador to Uganda stated, "To address Uganda's short-term needs, the American people will add new HIV funding above and beyond our current annual budget of $280 million. These new funds, invested over a two-year period, will increase enrollment of new patients by at least 36,000 this year, with an additional 36,000 patients next year."

Source: The Global Fund.

Fighting for Funding

Creating false conflicts, engaging in wishful thinking about efficiency, and praying for people to get well will not stop the crash of the people's immune systems. Untreated, people with HIV will die, often in the prime of life, leaving vulnerable children, grieving partners and parents, and depopulated communities. The position of AIDS activists is clear: If there is enough money for war and enough to bail out bankers, there's enough to save the millions of lives that will be lost if flat funding continues.

The U.S. accounts for a quarter of the global economy and a third of donor-country economies. UNAIDS estimates that the global AIDS funding need for 2010 is $26.7 billion, with more needed if we are to start treatment earlier with the better treatment regimens recommended under the new WHO treatment guidelines. Funding needs will continue to rise over the next five years to reach universal access.

If the U.S. decides to provide its fair share (about $9-$14 billion a year from 2010 to 2015), it will offer leadership for other countries to follow. Even if 2011 appropriations only reach $7.25 billion (and grow by $1 billion a year after that) and the U.S. directs $6 billion of that funding to the Global Fund over the next three years, we would be substantially closer to achieving the goal of universal access by 2015. If money is short, as the U.S. claims, the U.S. can join the international effort to make the financial sector pay a financial transaction tax that would fund global health investments (see "Could a New Tax Save the Lives of Millions of People With HIV Around the World?" in this issue).

But informed outrage alone will not put the U.S. back on track to providing its fair share of funding. Activists need to continue shrewd campaigns aimed at Congress and the White House. The consequences of inaction will be all too real for the millions who are diagnosed with dangerously low CD4 counts, for mothers hoping to prevent transmission during childbirth, and for the community at large, which would see dramatically lower transmission rates if universal access to treatment were achieved.

Brook Baker is a professor at the Northeastern University School of Law and a Policy Analyst for Health GAP.

This article was provided by ACRIA and GMHC. It is a part of the publication Achieve.
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